The grey suits deserve better treatment

Too many NHS managers? If we are not careful, argues Chris Ham, there will be too few

Health service managers, meeting at their annual conference in Harrogate, are under siege from all sides. The Welsh Secretary, John Redwood, has criticised the number of "men in grey suits" in the NHS and has placed a moratorium on appointments in Wales. The Labour MP Alan Milburn drew attention this week to a 35 per cent increase in management costs between 1992 and 1993 and has attacked the growth of NHS bureaucracy. And the independent Audit Commission has reported on variations in management costs in NHS trusts.

In their enthusiasm to respond to these criticisms, ministers have reduced the number of NHS managers. This has resulted in large-scale redundancies in some areas, and more are in the pipeline. In pursuing this policy, the Government risks cutting back too far, too fast. An organisation as large and complex as the NHS demands high-quality management, and a crude attack on bureaucrats will be counter-productive.

The irony here is that for much of the Eighties the need for effective management within the NHS was supported by politicians. The report produced in 1983 by the late Roy Griffiths at the invitation of Margaret Thatcher began the transformation of the health service from an administered organisation to a properly managed public service. The Griffiths report resulted in the appointment of general managers and was an important stimulus to achieving better value for money.

It was in this period that significant efficiency gains were made. The new breed of general managers started the process of making services more patient centred. The system under which doctors who shouted loudest got the biggest share of resources was turned upside down, and the NHS was transformed from a professionally dominated bureaucracy to a social business.

Not only this, but managers were also the shock troops who had a key role in implementing the NHS reforms in 1991. In the face of concerted opposition from doctors, nurses and other staff, the reforms could not have been introduced so quickly without the commitment and support of managers. All the more surprising, therefore, that managers have been rewarded by the current programme of redundancies and cutbacks. Of course, some managers have gained, but many more are on the jobs market or facing insecurity as health authorities are merged or abolished.

Good management is needed first and foremost if patients and staff are not to suffer. An organisation with an annual budget of pounds 40bn and employing one million staff cannot be run on the cheap. Doctors and nurses have to be paid, appointments and operations for patients planned and accountability for the use of resources maintained. The NHS also needs to think ahead to anticipate change and craft longer term strategies. All of this requires an investment in managers, as the best run companies are quick to recognise.

These arguments apply as much to the Labour Party as to the Conservative Government. If, as anticipated, Labour's policy forum endorses plans this weekend to move away from a market in health care, then a future Labour government will rely heavily on effective management as the main route for improved performance. The abolition of the market will undoubtedly result in savings, but it will place a premium on finding other ways of enhancing efficiency and responsiveness. Managers should occupy a central place in Labour's alternative health policy since without them doctors will regain the upper hand. Patients will be the losers if services are run more for the benefit of staff than of users.

Politicians of all parties should recognise that the delivery of their policies depends on managers who need to be well motivated and rewarded. By all means eliminate the volumes of paperwork which NHS reforms have produced, but at the same time acknowledge that health care does not function on auto-pilot. Managers have a key role in co-ordinating and leading the delivery of cost-effective services. The time has come to praise the grey suits, not to bury them.

Professor Chris Ham is director of the Health Services Management Centre at the University of Birmingham.